If you don't ask, they won't tell

In medicine, unlike much of the world, it is the questions one doesn’t ask that lead to trouble. When taking a medical history, the biggest enemies are time and fear. Time, because there is never enough to ask all the questions, listen carefully to all the answers, and pursue all the possible clues. Fear, because the natural reluctance to ask certain questions is a trap.

Sister  Birgit was a nun, a member of the order that owned and ran our hospital. She worked in administration, and everyone knew her as Sister Bee, the go-to person if you had a problem with the bureaucracy. She used to joke that sometimes one needed God’s scissors to cut through the red tape - and she was exceptionally good at it. 

She came to our residency clinic complaining of several weeks of variable urinary irritation and burning with some mild and intermittent supra-pubic discomfort. She denied any vaginal discharge, problems with periods, fever, back pain or abdominal pain. Her urine, a midstream and clean catch sample, showed a trace of protein and leukocytes on the dip stick, and the spun sample showed a few white cells under the microscope. Her symptoms suggested urinary infection and the relatively clear mid-stream sample was consistent with a simple urethritis. I treated her with antibiotics while awaiting the urine culture result.  It came back negative. 

Two weeks later she was back. Her symptoms were unchanged and her urine was still essentially clear. I asked about possible causes of local irritation: bubble-bath, soap, occlusive underwear, too much time on a bicycle saddle or in damp gym clothes (the hospital had a small gym and Sister Bee was a regular, known for both her fitness and her figure). None of these applied.

I told her I was stumped and suggested that perhaps she needed to see a urologist. She asked very quietly if it could be a sexually transmitted infection. She had been spending a great deal of time evenings and weekends with a male co-worker (pursuing a major project for work) and had ‘given in to temptation.’ It had only been once, and she was ‘sure he was clean’ but she wondered if she might have ‘picked something up?’ 

On exam, she had a friable and somewhat tender cervix and her cervical culture proved positive for gonorrhea. (As did that of the priest with whom she was working.) Her symptoms cleared with appropriate treatment for gonorrhea and her repeat ‘test of cure’ (TOC) culture was negative. But that isn’t the end of the story.

When I saw her after treatment to do a ‘test of cure’ culture, I apologized for missing the diagnosis originally, rather clumsily admitting that I hadn’t thought to ask her the questions about sexual activity that I wold have asked had she not been a nun. In truth, I said, I hadn’t decided to not ask; it had simply not crossed my mind. In reply, she said she felt partly to blame. She had been worried about the possibility of a STI at the first visit, but since I hadn’t asked, she convinced herself it could not be a consideration. 

This was long before Atul Gawande wrote about checklists, or Daniel Kahnemann described the difference between efficient System 1 and deliberate System 2 thinking, but it was the beginning of my awareness of the need to ask myself how certain I am of the diagnosis, what questions I have not asked, what information I have discounted, and what else might be in play.


 

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